A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Continuous bubbling in the water-seal chamber
Occasional bubbling in the water-seal chamber
Fluctuations in the fluid level in the water-seal chamber
Constant bubbling in the suction-control chamber
The Correct Answer is A
Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and fluid from the pleural space and impair lung expansion.
Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.
Choice C Reason: Fluctuations in the fluid level in the water-seal chamber are normal and expected, as they reflect changes in intrathoracic pressure during inspiration and expiration.
Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct because dopamine is a vasopressor that increases the contractility and stroke volume of the heart, which results in an increased systolic blood pressure.
Choice B Reason: This is incorrect because dopamine can cause tachycardia as a side effect, but this does not indicate a therapeutic effect. An increased radial heart rate can also indicate other conditions, such as anxiety, fever, or dehydration.
Choice C Reason: This is incorrect because dopamine does not reduce cardiac output, but rather increases it by improving the pumping function of the heart.
Choice D Reason: This is incorrect because dopamine does not reduce urine output, but rather increases it by stimulating the renal blood vessels and enhancing renal perfusion.
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the effectiveness of the chest drainage system.
Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.
Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or fluid in the pleural space, which can lead to tension pneumothorax or pleural effusion.
Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.
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